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Home My WebLink AboutBLD-19-000952 • Or Y.yR I d -.)..4.4 . e Permitlt 3 . �; a e } ..(i.:„. i "1. 5 Amount D-- �$ P r Permit expires 180 days from t issue date 311)-1q 1?5 '- . EXPRESS BUILDING PERMIT APPLICATION_ TOWN OF YARMOUTH g: Yarmouth Building Department , f'_ __ ' ' ' ' �� n- • 1146 Route 28 i South Yarmouth, MA 02664 L "6 17 2018 1 . (508) 398-2231 Ext. 1261 „;„e 4,..,c i CONSTRUCTION ADDRESS: tiV 25J4J�J /(I P ASSESSOR'S INFORMATION: • Map: Parcel: t7 OWNER CAL/I/45 Ifo l 'harSh,PRPSF`rr +i [/.edit LP- TEL. # 5,57—7(12E077 CONTRACTOR: DDREQ 4.sidentialNAME MAILING ADDRESS ,�5 /p�L EL �y 0 Commercial Est.Cost of ConnstfifctiQn`S /CXV. ad Home Improvement Contractor Lie.# Construction Supervisor Lie.# Worlgnap!s Compensation Insurance: (check one) �/�."(•`r am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares a.. Replacement windows:# a Replacement doors: # 'Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like �// Pool fencing *The debris will be disposed of at y f Q 0,0,9-4 %V or Location of Facility I declare under penalties of perjury that the statement herein contained are true and correct to the best of my knowledge and belief I understand that any false answer(s) will be just cause for denial or ocafion of my license and r.ros tio. under M.G.L.Ch.268,Section 1. Applicant's Signature: / L. r�/l / Date: z//020 /� Owners Signature(or . eL Ft JD f p attachment) r..�. . Ir�,tui a Date: !/p Ar $ ,1 Approved BY E Dates / 1 / Buil. g OfEci.or designee) EMAIL ADDRESS: ( (KcA k,TJ&cL f lifhDc,e aft, Zoning District �/ Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The ComrnonweaIth of Massachusetts _ _�/ Department of Industrial Accidents i 41111= 1 Congress Street, Suite 100 it I • Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 076- ZDdV74zi f oru p City/State/Zip: tet 4e0T adel 3 Phone 4: 597 737— t3-37 Are you an employer?Check the appropriate box: Type of project(required): I.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling • any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work9. ❑Demolition ❑ myself[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Budding addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contactors listed on the attached sheet These sub-contactors have employees and have workers'comp.insurance? 13. Roof repairs i 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14.0 Other Od 152,11(4),and we have no employees. [No workers'comp.insurance required] lSL N�e '�' P Uo e°/ 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.((» ��f `/ `' t Homeowners who submit this affidavit indiraring they are doing all work and then hire outside contactors must submit a new affidavit indicating such. pl/ 1/�G�L!! *Contractors that check this box must attached an additional sheet showing the name of the sub-contactors and state whether or not those entities have employes. If the sub-contractors have employees,they must provide their workers'comp.policy number. '71- 7A-1/ I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: C f Job She Address: (Ai' 3/it /v/ A,rgr City/State/Zip: y�Ahp0711 ' '73 . Attach a copy of the workers' compens n policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under/��the pains and penalties of perjury that the information provided above is true d correct Si mature: (2// 4 Date: 07 d 0/7 Phone#: Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: